Quality Of Care In Institutions Research Articles

Healthcare workers' experiences of caring for patients diagnosed with intellectual disability co-occurrent with psychiatric disorders.

WHAT IS KNOWN ON THE SUBJECT?: Intellectual disability (ID) involves problems with general mental abilities and affects intellectual functioning and adaptive functioning. People diagnosed with ID present higher levels of functional disability, which means they usually have difficulty or the inability to independently perform basic activities of daily living. Little to no attention has been paid to the issues of the mental health of people diagnosed with ID. Specifically, healthcare workers' experiences of caring for patients with IDPD have been neglected. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: The findings increase our understanding and partially address the knowledge gap regarding the situations and circumstances faced by healthcare workers in caring for patients diagnosed with intellectual disability co-occurrent with psychiatric disorders (IDPD). In cases of insufficient staffing, healthcare workers may be forced to ignore the individualized needs of patients so as to facilitate management. Healthcare workers may also feel frustrated by not being able to anticipate or deal with patients' unexpected problem behaviours or accidents. They adapt by adjusting their expectations of their patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Healthcare administrators need to understand the difficulties faced by staff in caring for patients diagnosed with IDPD, arrange appropriate in-service education to increase the healthcare workers' knowledge and skills in caring for patients diagnosed with IDPD, and create warm and supportive environments for them. The government department responsible for the management of ID patient care institutions should be able to regularly monitor the overall staffing and quality of care in these institutions. ABSTRACT: Introduction When intellectual disability co-occurs diagnosed with psychiatric disorders (IDPD), the impact of the burden of illness on the affected individuals, their caregivers, their family and friends, and the services that provide for them is particularly high. The issues of the mental health of people diagnosed with ID have received little, if any, attention. One specific area of neglect is healthcare workers' experiences of caring for patients diagnosed with IDPD. Aim The aim of this study was to understand healthcare workers' experiences of caring for patients diagnosed with IDPD. Methods A qualitative descriptive research approach and semi-structured interviews were used in this study. We interviewed 15 participants who had experience in caring for patients diagnosed with a dual diagnosis of IDPD. Findings Four themes were found, as follows: (1) Negative impacts of insufficient staffing on the quality of care, (2) Constantly worrying about harmful incidents, (3) Discovering effective ways to provide individual patient care and (4) Adjusting expectations and attitudes towards patients. Participants' experiences revealed that they perceived the importance and effectiveness of providing individualized care for IDPD patients. However, when staffing is insufficient, they may be forced to ignore the individualized needs of patients so as to facilitate management. They may also feel frustrated by not being able to anticipate or deal with patients' unexpected problem behaviours or accidents. In addition, they adapt by adjusting their expectations of the patients. Discussion The findings from this research help to fill the knowledge gap in our understanding of healthcare workers' experiences of and their perspectives on caring for patients diagnosed with IDPD. Implications for Practice Healthcare administrators need to understand the difficulties faced by staff in caring for patients diagnosed with IDPD, arrange appropriate in-service education to increase the healthcare workers' knowledge and skills in caring for patients diagnosed with IDPD, and create warm and supportive environments for them. The government department overseeing the management of institutions providing ID patient care should be empowered to conduct regular monitoring of the overall staffing and quality of care in such institutions.

PRS18 Unplanned 30-Day Hospital Readmissions Among Patients who have an Index Visit for Pneumonia: A National Readmission Database Analysis

Short-term readmission rates are critical quality of care measures valued by both healthcare providers and federal agencies. This study seeks to identify and describe characteristics associated with adult patients having a non-elective or unplanned hospital readmission within 30-days of an initial hospital admission index visit for pneumonia. The 2017 National Readmission Database from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, was used to identify adult patients who had an eligible non-elective index visit involving hospital admission related to pneumonia. Those who had an unplanned hospital readmission within 30-days were flagged. Descriptive statistics were reported and an adjusted logistic regression was completed to identify patient and treating facility characteristics associated with readmission. 266,576 eligible index visits were identified. Of the total sample of index visits, over 18% were flagged for having a 30-day readmission event. Characteristics associated with having an unplanned readmission included patient age, particularly being between 41-64 years old (aOR: 1.53; 95% CI: 1.39-1.67), those covered by Medicaid (aOR: 1.33; 95% CI: 1.27-1.40), patients whose index visit was for ≥8 days (aOR: 1.83; 95% CI: 1.70-1.97), and those whose index visit discharge was against medical advice (aOR: 1.81; 95% CI: 1.68-1.96). The Elixhauser comorbidity score was also statistically significant (p ≤ 0.001) in all analyses. Older adults made up 65.04% of the patient sample, but they were less likely to have a readmission event compared to younger adults (aOR: 0.87; 95% CI: 0.84-0.90). In a national, weighted representative sample of US pneumonia patients, 30-day readmissions were common. Middle-aged adults and those with comorbidities were at particular risk. Ongoing analysis within these demographics may improve patient care and institutional quality of care in the future.

Обзор международных исследований, посвященных последствиям нахождения ребенка в условиях институционализации: как добиться положительных результатов

The review is devoted to research in the field of institutionalization of children left without parental care, and aims to determine what improvements can be made to ensure the best result in the development of children in these conditions. The current model of institutionalization based on deprivation, negative factors of development, seems limited and outdated. The results of the research are considered within the framework of the bioecological model of development of W. Bronfenbrenner. The analysis of publications shows that there is convincing evidence that the quality of institutional care at the exosystem level has a significant impact on the well-being of children and provides long-term positive results in the physical, cognitive, behavioral and emotional development of the child. The review shows that when institutional care is combined with certain protective factors, it does not always lead to negative consequences in the child’s development. Countries that set higher standards of institutional care for children, and specialists who apply measures that correspond to the identified predictors of full-fledged development, can see that institutional care can be a viable option when adequate care based on a foster family is not possible.

No reason to change WHO guidelines on cleansing the umbilical cord.

Along with the individual trial findings the figure [contained in this comment]: Log odds of neonatal mortality associated with chlorhexidine cord cleansing by proportion of home deliveries in control group (A) and neonatal mortality in control group (B) is consonant with the current WHO guidelines for cord care to which we recommend no change. Cord cleanliness is part of the suite of hard-won improvements that accompany the increases in survival being seen worldwide. In settings in which neonatal mortality rates remain high we recommend the kinds of programme that have been associated with reductions in all-cause mortality. These include improvements in institutional quality of care and efforts to improve community-based practices both central to the 2014 Every Newborn Action Plan. (Excerpts) © The Author(s). Published by Elsevier Ltd. Open Access.

Abstract WP94: Clinical Outcomes of Unruptured Cerebral Aneurysms Treated With Clipping or Coiling in Japan: The J-aspect Study

Background: Evaluation of the overall clinical outcomes of stroke care is important for improving institutional quality of care. We performed a nationwide survey in Japan to analyze cases of unruptured cerebral aneurysms using the diagnostic procedure combination (DPC). Methods and Results: Certified neurosurgical training institutions in Japan provided data from the DPC database on patients hospitalized with neurosurgical diseases between April 1, 2012 and March 31, 2013. Patients hospitalized owing to unruptured cerebral aneurysms were identified from the DPC database based on the International Classification of Diseases (ICD)-10 diagnosis code (I671). We excluded patients with emergency admissions. We compared the mortality rates, modified Rankin Scale (mRS) scores, postoperative complications of patients who underwent clipping and coiling. With respect to postoperative complications, we evaluated the ratio of an event of complication (brain infarction, brain hemorrhage and cardiac infarction) and the number of complications (scored using patient safety indicators: PSIs and hospital-acquired conditions: HACs). We used hierarchical logistic regression models to estimate the odds ratios (ORs) for in-hospital mortality and complications. We identified 6329 patients with unruptured cerebral aneurysms (3710 clipping, 2619 coiling). Patient characteristics, mortality rates, and mRS were similar between groups. Patients who underwent coiling had a significantly lower number of complications than patients who underwent clipping (PSIs: OR = 0.40; P < 0.001, HACs: OR = 0.47; P = 0.001). Adversely, there was an increased likelihood of ischemic stroke in coiling patients compared with clipping patients (coiling: 7.2%; clipping: 4.7%; OR = 1.37; P = 0.011). 83.2% of coiling patients underwent MRI after the operation, compared with 37.3% of clipping patients. Conclusions: Our data demonstrated that coiling patients had lower number of post-operative complications and higher number of ischemic stroke than clipping patients. But the cause that higher number of coiling patients had ischemic stroke than clipping patients because higher number of coiling patients were underwent MRI after operation compared with clipping patients.

Vulnerability and resilience after early institutional care: The Greek Metera study.

The aim of the study was to examine possible influences on individual differences in adolescence in response to early institutional care in infancy not involving either generalized privation or subnutrition. Fifty-two adopted adolescents aged 13 years who received institutional care in infancy at the Metera Babies Centre and 36 adolescents of the same age who were raised in their biological families participated in the study. Adolescents' attachment relationships, cognition, behavioral adjustment and use of psychological services were assessed. Marked heterogeneity in outcomes was found. No predictive effects were found for preinstitutional features or for adoptive circumstances. By contrast a large effect was found for institutional care extending beyond the age of 2 years and for quality of institutional care as experienced at an individual level. There was a close association between prolonged institutional care and disorganized attachment while in the institution, but the main institutional effect derived from the length of time in the institution.

Abstract W MP42: Nationwide Database of Unruptured Cerebral Aneurysms Treated With Clipping or Coiling in Japan: The J-ASPECT Study

Background: Evaluation of the overall clinical outcomes and health economics of stroke care is important for improving institutional quality of care. We performed a nationwide survey in Japan to analyze cases of unruptured cerebral aneurysms using the diagnostic procedure combination (DPC). Methods and Results: Certified neurosurgical training institutions in Japan provided data from the DPC database on patients hospitalized with neurosurgical diseases between April 1, 2012 and March 31, 2013. Patients hospitalized owing to unruptured cerebral aneurysms were identified from the DPC database based on the International Classification of Diseases (ICD)-10 diagnosis code (I671). We excluded patients with emergency admissions. We compared the mortality rates, modified Rankin Scale (mRS) scores, postoperative complications, and economic factors of patients who underwent clipping and coiling. With respect to postoperative complications, we evaluated the ratio of an event of complication (brain infarction, brain hemorrhage, cardiac infarction, and meningitis) and the number of complications (scored using a hospital-acquired condition). We used hierarchical logistic regression models to estimate the odds ratios (ORs) for in-hospital mortality and complications. The case volumes of clipping and coiling in each hospital were divided into quintiles, and trends were analyzed using the Cochran-Armitage trend test. We identified 5194 patients with unruptured cerebral aneurysms (3287 clipping, 1907 coiling). Patient characteristics, mortality rates, and mRS were similar between groups. Patients who underwent clipping had a significantly higher number of complications than patients who underwent coiling (β = -0.04; P = 0.03). Cases of brain infarction that had developed during hospitalization in both patients who had undergone clipping (OR = 0.28; P = 0.02) and patients who had undergone coiling (OR = 0.24; P = 0.047) were fewer in high-volume hospitals. Conclusions: Our results estimate the baseline national rates of outcomes and health and economic factors in patients with unruptured cerebral aneurysms that were treated with clipping or coiling. Our data may be useful for assessing institutional quality of care in comparison with national data.

Research on Institutionalized Children: Implications for International Child Welfare Practitioners and Policymakers

This paper reviews the empirical literature on the effects of institutionalization on young children’s development from the perspective of global child welfare practice and policy. It considers the characteristics of typical institutions, how to assess the quality of care in institutions, the level of physical and behavioral/mental development of infants and young children while residing in institutions, the crucial role of caregiver–child interactions in children’s development, the potential of children to developmentally improve when institutional caregiver–child interactions improve or children are transferred to families, and the influence of the quality of care on children’s development regardless of context. Several controversies are considered in a balanced fashion and from the standpoint of the nature of the evidence, such as care as typically practiced versus more ideal care, intercountry adoptions, improving institutions, and volunteers in institutions. Implications for practice and policy are identified throughout, especially factors that characterize successful large-scale attempts to transition from institutionalization to a system of family alternatives.

Quality of institutional care and early childhood development

Institutional rearing adversely affects children’s development, but the extent to which specific characteristics of the institutional context and the quality of care provided contribute to problematic development remains unclear. In this study, 72 preschoolers institutionalised for at least 6 months were evaluated by their caregiver using the Child Behavior Checklist and the Disturbances of Attachment Interview. Distal and proximate indices of institutional caregiving quality were assessed using both staff reports and direct observation. Results revealed that greater caregiver sensitivity predicted reduced indiscriminate behaviour and secure-base distortions. A closer relationship with the caregiver predicted reduced inhibited attachment behaviour. Emotional and behavioural problems proved unrelated to caregiving quality. Results are discussed in terms of (non)-shared caregiving factors that influence institutionalised children’s development.

Quality of Care and Mortality among Long-term Care Residents with Dementia

Seniors with dementia who enter long-term care facilities are at greater risk of death than are similar individuals that remain in the community. Previous research has focused primarily on social selection factors such as health status to explain mortality in this population. This study seeks to determine whether resident mortality within 12 months of admission to a facility can be explained by post-admission social causative factors, that is, by institutional quality of care. Logistic regression results are based on the study of 402 residents in 73 long-term care facilities throughout British Columbia, Canada. Mortality data were obtained from Vital Statistics. Although social selection factors (e.g., physical dependency) emerge as the strongest predictors, one social causative factor – facility level restraint use – also predicts mortality. This study provides some evidence that social causative factors play a role in determining mortality among long-term care residents with dementia. Further research on the social causative factors is needed to understand the degree to which they affect mortality, and the way in which they do so.

Managerial Styles and Institutional Control

Based on a 30-year examination of managerial styles at a maximum-security training school in Ohio, this study examines three managerial styles that emerged: charismatic, bureaucratic, and technocratic. Extensive interviewing with staff members, some of whom had been present during the 30-year period, identified that the three basic managerial styles could be further divided into five categories: (a) charismatic control, (b) charismatic reform, (c) bureaucratic control, (d) bureaucratic reform, and (e) technocratic control. The thesis proposed in this article is that the management styles will, to a large degree, effect the quality of life that takes place within juvenile correctional institutions, especially training schools. The various management styles are evaluated concerning what they contributed to the quality of institutional care, and a number of general managerial recommendations based on the findings of this study are offered to guide the improvement of juvenile care in long-term training schools.

Long-term Care Insurance and Optimal Taxation for Altruistic Children

We model long-term care insurance in an optimal taxation framework. Every adult decides upon the amount and type of care he purchases for his dependent parent. We consider two alternatives: nursing-home care provided by the government, and home care paid by the child with some lump-sum subsidy by the government. The only source of information asymmetry is the government's inability to observe the degree of altruism of the adult child for his/her parent. Further tax collection entails some social costs. In such a second-best setting, we show that the quality of institutional care has to be kept relatively low and that compared to altruistic children, nonaltruistic ones enjoy a high level of consumption.

Long-Term Care Insurance and Optimal Taxation for Altruistic Children

We model long-term care insurance in an optimal taxation framework. Every adult decides upon the amount and type of care he purchases for his dependent parent. We consider two alternatives: nursing-home care provided by the government and home-care paid by the child with some lump-sum subsidy by the government. The only source of information asymmetry stems from the governments inability to observe the degree of altruism of the adult child for his/her parent. Further tax collection entails some social costs. In such a second best setting, we show that the quality of institutional care has to be kept relatively low and that compared to altruistic children, non-altruistic ones enjoy a high level of consumption.

Dis/integrated care: family caregivers and in-hospital respite care.

The aim of this study was to explore family caregivers' experiences of in-hospital respite care for people with dementia and the factors that influenced their perceptions of the service. The provision of respite care is based on the assumption that temporary relief from caregiving will relieve caregiver stress and may possibly extend the duration of home care. Research evidence suggests that this is a simplistic perspective which fails to account for families' concerns about the quality of institutional care and the impact of relocation on the person being cared for. Nine family caregivers, using four different hospitals sites were interviewed during a period of 3 years from 1994 to 1997. The research texts were analysed using a critical discourse analysis approach drawing on the work of Foucault. Family caregiver texts were distinguished by difference rather than by homogeneity. Caregivers occupied a range of positions in terms of their ability to take advantage of the respite time intermittent care offered. My reading of these texts has highlighted the aspects of nurse-family relationships that ameliorated, or alternately exacerbated, the tensions felt by caregivers, as they were torn between the necessity to have a break and their anxieties about the impact of in-hospital respite care on the person with dementia. Nurses' practices in this study were a critical element in facilitating, or alternately constraining, family caregivers' ability to relinquish care and to take full advantage of the respite time. The research findings highlight the need for nurses and other formal caregivers to locate themselves in a secondary and supporting caregiving role, to acknowledge the family caregivers as the primary caregiver, and use family caregivers in-depth and intimate knowledge of the needs of their relative to inform care within the institutional setting.

Improving institutions: Effects of small unit size on quality of care of people with severe intellectual disabilities

Two studies analysed the effects of small unit size of six to eight residents on the quality of care in institutions for people with intellectual disabilities. The results showed improvements in small units when compared with larger wards with 10 to 20 residents. Overall, the outcomes were small or modest, and the quality of care remained below standards typically achieved in community environments.

Improving the quality of institutional care of urinary incontinence among the elderly: a challenge for governmental regulation.

This article describes actual UI prevalence and quality of care at Israeli LTC institutions for the elderly. The analysis is based on current regulatory data on 14,406 residents at 196 residential homes, and 8,278 patients at 159 hospitals for the chronically ill. It includes a calculation of summary indices of quality, the percentage of institutions with deficient items and of those showing change, and a description of functional status profiles. Multiple regression explains the deficiency rate variance through independent institutional variables. There is a higher prevalence of severe functional impairment and full incontinence at hospitals for the chronically ill than at residential homes. There were higher rates of deficiencies and lower rates of corrections for structural items than for process items at both. A major improvement occurred for process items (50-100 per cent). Regarding outcomes, 34 percent of the residents with UI during the first assessment were continent two years later.

An innovative method of government surveillance of services for the aged in Israel

Explains the conceptual framework behind and the foundation and implementation of the regulation, assessment, follow-up (RAF) method, and continuous improvement of quality of care in the Israeli Government surveillance of long-term care institutions. The RAF method has made crucial changes in the goals, tasks and tools of surveillance and in therapeutic approaches to the elderly. The "maintenance approach" has been replaced by a "rehabilitative approach" bringing about a real improvement in the quality of care in institutions. Presents selected findings from an evaluation of the RAF method's use in the surveillance system operated by the Israeli Service for The Aged of the Ministry of Labor and Social Affairs.

Looking at them, looking at me. A review of observational studies into the quality of institutional care for elderly people with dementia

The nature of dementia is such that traditional methods of gaining users' views regarding services (interviews, questionnaires, focus groups) cannot be regarded as reliable. Thus, evaluations of care usually include observation of users behaviour and/or the care process. Observational methods employed have varied from study to study but most often attempt to quantify type and levels of residents' activity. Most evaluations are cross-sectional in design and bear witness to the fact that people with dementia living in long-stay settings spend long periods doing nothing. More recent observational techniques such as the Quality of Interactions Scale (QUIS, Dean et al., 1993) and Dementia Care Mapping (Kitwood & Bredin, 1993) attempt to consider the quality as well as the quantity of activity. The latter sets standards of excellence in dementia care but its practical use in improving standards is yet to be fully proven.

Improving regulation of care.

The JDC-Brookdale Institute of Gerontology, in collaboration with Israel's Ministry of Labor and Social Affairs and Ministry of Health, has developed a program to improve government regulation of long-term care institutions for the elderly, and thus the quality of institutional care. The aim of the program was to introduce greater uniformity and objectivity into the existing surveillance system, increase the participation of institution residents, and ensure public access to instruments and criteria. The tracer methodology was used and tracers representing the medical, nursing, psychosocial and environmental-operational areas were developed in consultation with specialists in each field. The program was welcomed by surveillance personnel, and implemented on a nation-wide basis. Although there have been difficulties with its implementation, these have largely been resolved through discussion, workshops and supplementary training for surveyors. Due to the program's success, new programs are being developed to improve the regulation of other kinds of institution.

Quality of institutional care and the elderly: policy issues and options.

The debate about standards of care provided in private nursing homes and rest homes has so far been conspicuously short of systematic evidence and specific proposals. Is the quality of care in the private sector inadequate and, if so, in what respects? Does the system of public regulation need to be tightened up and, if so, what changes are needed? These are the questions prompted by public concern. But before addressing them it is important to emphasise that the way in which they are usually presented risks falling into a trap. This is to assume that there is necessarily something special about the private sector of institutional care for the elderly: some form of original sin exclusive to the provision of care for profit. We shall argue that, on the contrary, most of the problems of regulation can be understood only if they are seen as stemming from the nature of institutional care for the elderly, whether publicly or privately provided. If there is concern about standards (as there should be) then it should be an across the board concern. If there is a case for discussing ways of improving the existing machinery for safeguard? ing standards (as there is) then again the policy options should be examined in the context of the public and private sectors of institutional care taken as a whole. Taking the latest available figures, for 1984, there were about 280 000 places for the elderly in England in a variety of institu? tions.12 Of these, approximately 53000 (19%) were in National Health Service geriatric hospitals and 28000 (10%) in nursing homes; 110000 places (39%) were in local authority residential homes and about 90 000 (32%) in private and voluntary rest homes. So in 1984 private provision, which we define to include voluntary homes, accounted for over two fifths of all institutional places for the elderly. Indeed throughout the 1980s private nursing and rest homes have been increasing their share of total institutional provision. While the number of geriatric beds has been falling slightly and local authority provision has barely increased the number of private nursing home beds went up by 35*6% between 1982 and 1984. The number of private residential home beds rose by 42*2% over the same period. The growth of the private sector in part reflected changes in the supplementary benefits system, although it had started well before the introduction of new rules in 1983 and has since slowed down. As a result of the change in the supplementary benefits rules social security payments now support about two fifths of all the residents in the private sector.3 In total, supplementary benefits payments to people in private sector homes rose from ?105 million in 1983 to an estimated ?500 million in 1986. In this article we explore the wider concerns in the particular case of nursing homes, which account for roughly a quarter of institutional places. In doing so we draw on interviews and documentary material generated by a research project that is examining the way in which health authorities carry out their statutory responsibilities for registering and inspecting nursing homes.4 We do not attempt to look at the regulation of private residential homes by local authorities although this has given more cause for anxiety, some of which has rubbed off on to nursing homes. Although each of the sectors of institutional care?public and private, nursing and residential?undoubtedly has its own special characteristics and problems, our main interest hereis with issues common to all of them.